Despite the growing need for medical eye care services, more than 70% of the average optometrist’s income still comes from goods and services related to glasses and contact lenses.1 But challenges from online vendors and the advent of virtual or automated vision screenings will make it increasingly difficult to succeed at this model.
Meanwhile, the demand for medical eye care services is expanding at a rate nearly three times that of comprehensive eye exams. Someone must care for these patients and, in many cases, this responsibility is ours.
Assess the Need
If you look at the specific areas where medical eye care services are growing, several specialties stand out:
• Diabetes. Diabetic retinopathy (DR) is a leading cause of vision loss.2 According to the American Diabetes Association, the annual economic burden of diabetes is about $245 billion.3 Further estimates speculate that the total cost of diabetes attributable to DR ranges anywhere from 10% to upwards of 42%.4 Optometrists can play a leading role in early detection and appropriate management, since many adults living with diabetes remain unaware of their condition until their DR has progressed to a stage at which treatment is difficult. For example, of an estimated 285 million people worldwide with diabetes, more than a third have signs of DR, and a third of these are afflicted with vision-threatening DR.5
• Cataract. Rising patient expectations and a growing number of surgical options have expanded the cataract pre-op evaluation. Patient selection is a primary component in achieving satisfactory visual outcomes after cataract surgery, and the results depend heavily on the quality of the ocular surface.
Ocular surface disease increases the risk of surgical complications, affects intraocular lens (IOL) measurements and impacts comfort and quality of vision. In fact, research shows that patients who have osmolarity scores within normal limits are within a half diopter of intent, whereas 17% of those with hyperosmolarity would have missed their IOL calculation by more than a diopter.6 For post-op care, a new formulation of loteprednol 0.38% (Bausch + Lomb) is likely to be available soon. This drug uses key polymers and a submicron particle size to allow for higher potency and penetration with a lower concentration of drug.
• Glaucoma. An estimated 61 million people had glaucoma as of 2010, and the number may rise to 80 million by 2020.7 Fortunately, advanced technologies and new therapeutics can help with early detection and management. We now have several new drugs as well as modified or preservative-free versions of early-generation drops. Some of these affect outflow in novel ways and show significant promise for improving patient care. In addition, new surgical devices such as MIGS have improved intraocular pressure control and are a good opportunity at the time of cataract surgery.
• AMD. Clinical AMD is more prevalent than glaucoma and DR combined—and by the year 2050, it is estimated to double. Unfortunately, both optometrists and ophthalmologists are missing AMD about 25% of the time.8 It’s no wonder that as many as 78% of patients are first diagnosed with AMD after having already suffered irreversible vision loss in one eye, and nearly half of them are first diagnosed with an acuity of 20/200 or worse.9 One of the best ways to improve these statistics is to start testing dark adaptation time. This functional test allows you to detect early AMD up to three years before it becomes clinically evident and it takes the guesswork out of AMD diagnostics so you can move forward with a plan to slow or prevent progression.
• Dry eye. In the United States, managing dry eye costs healthcare $55.4 billion annually—and the demographic most likely to suffer is growing.10 A few decades ago, there wasn’t much we could do to address dry eye in a meaningful way. But our options are expanding. Several years ago, a better understanding of the inflammatory process led to the introduction of two modern mainstays of dry eye therapy, cyclosporine and lifitegrast. Today, these advanced pharmaceuticals are being joined by more treatments. Cequa (cyclosporine A 0.09%, Sun Pharmaceuticals) is a preservative-free nanomicellar formulation of cyclosporine A in a stronger formulation than has been previously available. Klarity-C (cyclosporine 0.1%/chondroitin sulfate ophthalmic emulsion) is another compounded dry eye drop that’s available through Imprimis. KPI-121 (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals) uses a mucus-penetrating particle technology to increase the penetration of a familiar steroid. P-321 (Shire), an epithelial sodium channel inhibitor for the treatment of tear volume deficiency and the promotion of ocular surface healing, is also under investigation. Beyond pharmaceuticals, we also now have access to other efficacious dry eye and meibomian gland dysfunction treatments, including intense pulsed light, neurostimulation and thermal pulsation.
Make a Difference
If you haven’t embraced medical eye care, this is the year to do it. If you have, maybe consider adding a specialty to your practice. We must take a more active role when treating patients with diabetes, cataract, glaucoma, AMD and dry eye. Beyond our training as diagnosticians, we can recommend treatments that make a meaningful difference, and we can suggest lifestyle changes, diet and exercise modifications, systemic disease management, nutritional supplementation, retinal light protection and more careful follow-up.
Medical optometry will change the lives of your patients, and it will change the course of your practice in meaningful, positive ways. The top 5% of optometrists receive at least 50% of their income from medical services.11 How much of your practice revenue can you attribute to medical optometry? For most of your colleagues, it’s only about 17%, which leaves plenty of room to grow in a diverse list of specialties that show no signs of shrinking.11
Note: Dr. Karpecki consults for a number of manufacturers with products relevant to this topic.
1. AOA Excel and Jobson Medical Information. The State of the Optometric Profession. 2013.
2. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis. 2015;2:17.
3. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36:1033-46.
4. Summers KHR, Ryan GJ. The economic impact of diabetic retinopathy and the promise of emerging therapies [CE Activity]. International Medical Press; 2007.
5. Yau JW, Rogers SL, Kawasaki R, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012;35(3):556-64.
6. Epitropoulos AT, Matossian C, Berdy GJ, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41(8):1672-7.
7. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90:262-7.
8. Neely DC, Bray KJ, Huisingh CE, et al. Prevalence of undiagnosed age-related macular degeneration in primary eye care. JAMA Ophthalmol. 2017;135(6):570-5.
9. Cervantes-Castañeda RA, Banin E, Hemo I, et al. Lack of benefit of early awareness to age-related macular degeneration. Eye. 2007;22(6):777-81.
10. Yu J, Asche CV, Fairchild CJ. The economic burden of dry eye disease in the United States: a decision tree analysis. Cornea. 2011;30(4):379-87.
11. Management & Business Academy. Key Metrics: Assessing Optometric Practice Performance. 2015 Edition.